Optometry Billing Services

Modifier -25 for Minor Retina Surgeries

The growth of intravitreal drug therapy for the treatment of retinal diseases over the past decade has been unprecedented. The number of intravitreal injections performed annually in the United States rose from less than 3000 in 1999 to more than 1 million in 2008, and it is estimated that more than 7 million intravitreal injections will be performed in the United States in 2017. The therapeutic benefit of these treatments is both inarguable and profound. Correct coding and billing of intravitreal injection (CPT code 67028) are critical to optimal practice management.

Minor Retina Surgeries

The most common retina procedure with a 0-day Medicare global period is:

  • 67028 Intravitreal injection of a phar­macologic agent (separate procedure)

Common retina procedures with a 10-day Medicare global period are:

  • 67101 Repair of retinal detachment, in­cluding drainage of subretinal fluid when performed; cryotherapy
  • 67105 Repair of retinal detachment, in­cluding drainage of subretinal fluid when performed; photocoagulation
  • 67227 Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), cryotherapy, diathermy
  • 67228 Treatment of extensive or progressive retinopathy (e.g., diabetic retinopathy), photocoagulation

Note: Commercial payers that do not follow CMS’ global periods may still have a 60- or 90-day global period for codes 67101, 67105, 67227, and 67228. With those payers, the pro­cedures would be considered major procedures (because the global period is greater than 10 days), and you would append modifier –57 to the appropriate level of exam. Modifier –57 indicates that it is the exam to determine the need for major surgery.

Billing for E/M Service

CPT code 67028 has a zero-day global period, meaning it is considered a minor surgical procedure by Medicare. As a general rule, evaluation, and management (E/M) services performed on the same day as a minor surgical procedure are bundled into the procedure. However, when there is significant, separately identifiable work, an E/M service may be billed using modifier -25.

The CPT definition of modifier -25 is” Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” Its use is indicated when a patient’s condition requires a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service being reported.

For ophthalmologists, it is important to note that the eye codes (92002, 92004, 92012, 92014) are reportable E/M services. The E/M service may be prompted by the symptom or condition for which the procedure or service was provided. Therefore, different diagnoses are not required for reporting the E/M services on the same date. This circumstance may be reported by adding modifier –25 to the appropriate level of E/M service.

Modifier -25 and Intravitreal Injections

Based on the definition of modifier -25, the American Academy of Ophthalmology (AAO) has repeatedly published guidelines on the correct use of this modifier for intravitreal injections. These guidelines have been presented to the Centers for Medicare and Medicaid Services (CMS), both in writing and at meetings, with the specific request that if CMS disagrees with these guidelines it should inform the AAO. To date, CMS has not notified the AAO of any disagreement.

The National Correct Coding Initiative (NCCI) is responsible for determining correct coding, particularly for the role of combining or bundling procedures when appropriate. When the NCCI determines that there is no scenario in which an E/M service can be used with another procedure or service, an unbreakable bundle (category 0) is created. This means that these two codes are always bundled and that payment for the E/M service is always inappropriate. When NCCI determines that there are valid clinical reasons to allow an E/M service to be used on the same day as a minor surgical procedure, it allows the use of the appropriate modifier (category 1) with appropriate supporting documentation. Currently, NCCI allows the use of modifier -25 for an E/M service provided on the same day as an intravitreal injection.

It is important to note that CMS is fully aware that E/M services are billed with intravitreal injections more than 50% of the time. This fact is accounted for in the valuation of CPT code 67028. Given the above, when is it correct to use modifier -25 with an intravitreal injection? The clinical scenarios on the next page provide some clarification.

There are two primary factors to consider when determining whether an E/M service should be billed with modifier -25.

Factor No. 1: Determining Injection Need

If the examination is performed to determine the need for an injection, the use of modifier -25 for an E/M service is appropriate. By contrast, if the examination is performed to confirm the need for a previously determined injection, the use of the modifier for an E/M service is inappropriate.

Factor No. 2: Examining the Fellow Eye

It is important to remember that age-related macular degeneration (AMD) and diabetic retinopathy are bilateral, chronic diseases. It is the good medical practice to examine the fellow eye on a regular basis. How frequently such examinations should occur and at what level is a matter of clinical judgment and depends on the state of disease in each patient. When the fellow eye is examined, an E/M service is often appropriate, assuming medical necessity.

Not-so-simply Stated

The use of modifier -25 in conjunction with intravitreal injection is often, but not always, appropriate and correct coding that recognizes the performance of a significant, separately identifiable service when there is a medical necessity.

The common clinical scenario that demonstrates when modifier -25 is appropriate

  • A patient returns for a scheduled examination for neovascular age-related macular degeneration (AMD). The patient received prior injections. The examination shows no evidence of complications from the previous treatments and it is determined that an additional injection is needed that day.
  • A patient presents with recent vision loss in his left eye. Examination and imaging demonstrate active choroidal neovascularization (CNV) due to AMD. The patient is treated with an intravitreal injection of an anti-VEGF drug.
  • A patient who has received multiple intravitreal injections in her left eye to treat AMD returns to her specialist complaining of vision changes in her right eye. Examination reveals progressive geographic atrophy in the right eye and an active CNV in the left eye. The left eye with injected with an anti-VEGF drug.
  • A patient is on a PRN treatment regimen for CNV in her left eye. The patient did not receive treatment at the last visit. Today, active CNV is noted on examination and imaging. The patient’s left eye is injected.

The common clinical scenario that demonstrates when modifier -25 is not appropriate

  • A patient returns for a previously scheduled injection in the left eye. Ocular examination confirms the need for the injection. Modifier -25 is not appropriate in this situation.
  • A patient with bilateral CNV returns for follow-up. Examination and imaging confirm bilateral active CNV. The right eye is injected today. The patient returns in 3 days for injection of the left eye. Modifier -25 is appropriate for the right eye, but not when the patient returns for the previously determined injection in the left eye.
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